Intervention Pain Clinic

For Referring Physicians

Streamlined Referrals. Specialist-Level Care.

A referral from any licensed physician or nurse practitioner is required to be seen at our clinic. Submit your referral online using the form below, or download and complete our referral form electronically or manually and fax it to our clinic.

How the Referral Process Works

01

Submit a Referral

Complete the online referral form below, or download the PDF or Word form, fill it out, and fax it to the appropriate clinic location.

02

Triage & Scheduling

Our referral coordinators review each submission and contact the patient directly to schedule an appointment. Urgent cases are prioritized.

03

Specialist Consultation

The patient is assessed by one of our CPSO-licensed interventional pain physicians. A comprehensive treatment plan is developed.

04

Consultation Report

A detailed consultation report is sent to the referring physician following each visit, keeping you fully informed of findings and the management plan.

Clinic Locations

Chatham Location

Serving Chatham-Kent and surrounding areas since 2017

547 Queen Street, Chatham, Ontario, N7M 2J4
Ph: 519 360 9000
Fax: 519 360 9006
Monday to Friday
Level 2 OHP Facility (OHPIP)
Landmark technique and ultrasound guidance
OHIP covered and non-OHIP covered procedures

Cambridge Location

Serving Cambridge and nearby communities since 2021

Unit 102 – 1150 Franklin Blvd, Cambridge, Ontario, N1R 7J2
Ph: 519 620 0606
Fax: 519 620 9339
Monday to Thursday
Level 2 OHP Facility (OHPIP)
Landmark technique, ultrasound guidance, and fluoroscopy/X-ray guidance
OHIP covered and non-OHIP covered procedures

Download Referral Form

Prefer to fax? Download our referral form, complete it electronically or by hand, and fax it to the appropriate clinic location.

Download PDF FormDownload Word Form

Online Referral Form

Complete the form below. All fields marked * are required. Supporting documents (X-ray, MRI, CT, blood tests, consult letters) can be faxed to the clinic.

Patient Profile
Referring Physician Profile

Please indicate as applicable

Reason for Referral

Please indicate as applicable

Intended Location of Service

Attach Supporting Documents (optional)

Upload relevant diagnostic imaging, specialist consults, or medication lists. Accepted: PDF, JPG, PNG, TIFF, WEBP — up to 20 MB each, max 10 files.

Click to attach files or drag and drop

Prefer to send by fax? You can also send documents to your intended location:

IPC Chatham

547 Queen Street, Chatham, ON N7M 2J4

Ph: 519-360-9000  |  Fax: 519-360-9006

IPC Cambridge

Unit 102 – 1150 Franklin Blvd, Cambridge, ON N1R 7J2

Ph: 519-620-0606  |  Fax: 519-620-9339

Have a general question? Contact us here